The Trolley Paradox
by Danzinora Switch
Summary: "If killing five people saves ten, then it's a bargain." -Operation: Annihilate. McCoy faces the decision, and consequences, of a medical no-win scenario. This just might be what destroys him. Rated T for medical imagery.


**A/N: Hello again, trekkies and trekkers. This story is bittersweet at best, though I do have plans for a sequel to resolve a few extraneous issues. For now, I will simply cite the episodes from which I pull quotes and references: Wrath of Khan, Return to Tomorrow, The Empath, The Man Trap and The Final Frontier. In that order... don't think I missed any. I don't own Star Trek, of course.**

 **Well, enjoy. Or don't. You might hate this. Feel free to feel whatever you like, so long as you read this :)**

* * *

The situation was bad.

As in, world-crashing-down-around-you bad.

McCoy had been in medical crises before. He's normally the person to call when a plague is rampaging through a planet, or when refugee camps need drastic medical treatment. He'd worked in hospitals while bombs were raining in the city. He's headed M*A*S*H* units. He's coordinated anything from treatment plans to emergency evacuation systems.

He's delegated tasks while elbow-deep in someone.

He finds cures and listens to patients' life stories.

He's worked in ambulances, in tents, in state of the art hospitals, and in open fields.

The point is: in a widespread medical crisis, McCoy is more than competent.

Thus, the situation on Kathala III should be no different.

It was a quiet little planet that had first been happened upon during the Vulcan Exploration Age. Fortunately, it was after Surak, and after thwarting some Orions looking to cause trouble Vulcan took the small system under its wing as a protectorate. Nobody minded. The natives continued on with a rather simple life.

The distress signal had gone out when a series of record-breaking earthquakes swept across the little world. The _Enterprise_ and a few dozen other ships all responded in the wake of such disaster. McCoy found himself working day and night in a cramped, makeshift hospital as wave after wave it seemed of victims were brought in.

He caught naps stretched out on the floor by a wall- all benches were taken for the wounded. His staff and other volunteers under his command were a blessing and worked diligently. Whenever someone was stable, they got moved out to where some shuttles and other vehicles could transport them to larger facilities. Then there would be a lull before new unburied people were brought in.

It was, in a sense, the front lines of medical treatment.

He dragged a hand across his face and wearily looked around the room. There were more benches, tables, and beds open. This lull was lasting longer than the others. Maybe the load was finally beginning to slacken.

Maybe they'd reached the point where the diggers were uncovering corpses more than they were wounded.

There was a shout at the door signaling the end of the brief respite. A truck had backed up and everyone scrambled to unload the patients. Stretchers, makeshift crutches, and other people were all used to carry them in. McCoy barked orders on where to lay them and for what treatments they would need. Everyone responded automatically- after several days of this, hardly anyone needed to be told what to do anymore.

McCoy suddenly found himself with five people who had all been uncovered from the same building. Most looked like family, from what he could tell. There was a small girl of about seven years old with them, still curled around her mother. Despite the grime, he could tell she had blond hair.

He got them settled and quickly started scanning everybody. With every reading his stomach dropped.

This was a nightmare.

One person- perhaps the dad, or an older brother, had a jagged rock in his pancreas, completely destroying it. The mother had a lung riddled with holes and was suffering dust inhalation in both of them. The daughter, small as she was, had damage to her kidney… her only kidney, McCoy realized with alarm. The last two men were also in bad shape: one had severe blood loss and the other had dangerous injuries to his heart.

"These people were brought here just in time," he murmured aloud.

But it presented a problem- they needed parts. It was a miracle already that any of them had survived the trip over.

McCoy took a deep breath. "Okay. Let's figure this out."

He managed to close a few wounds- it helped keep some blood in, and he started clearing out the woman's lungs, but one couldn't be saved and the other wasn't strong enough to support her on its own. The child and male relative still needed a kidney and pancreas, and the other man's heart…

"Doc! Got another one!"

McCoy only turned his head to where a few "paramedics" were carrying in another man. He was unconscious, and the nasty gash on his head was probably why. Other than that, he seemed fine. McCoy pointed to a chair and finished closing off a vein in on man's side. There. He still needed blood, though, and suffered severe shock.

Quickly, McCoy scanned over the man to see how serious the gash was. It would be an easy fix- no questionable triage decisions by a long shot, he could wait. But his eyes froze on the rest of the readings.

The readings that had burned into his brain.

The clamor of the medical station faded away as he turned to his five patients, his heart thudding in his ears.

A match.

Kidney, pancreas, lung- was he related to this family? His blood type and heart, too, would work for those McCoy was beginning to think were twins.

He stepped back as his brain reeled. There was no way. He triple-checked everyone's vitals. A match. A match, a match, a match. A match.

He wasn't stupid. The odds of such a thing happening- he imagined Spock would know. It felt like some divine force had plopped the drifter down in front of McCoy with a wink and a "you're welcome".

It solved his problems.

Did it?

McCoy stepped back again, darkness encroaching around his swirling mind. Could he do such a thing?

He was a doctor.

Not God.

He looked at his patients. The little girl blinked her eyes. She was Joanna's age, the last time he saw her in person.

It felt like a knife ripped through his heart.

Furiously he looked between his patients. He rubbed his eyes. He paced forward and between them. He looked up and around the hospital desperately, but everyone was busy.

No. He wouldn't force this decision on his staff.

 _I need those organs for the others…_

 _Thou shalt do no Harm…_

 _It's within my ability to save them! I must give my all!_

 _I can't play God…_

 _The needs of the many outweigh the needs of the few._

 _I won't peddle flesh!_

"Boy," McCoy croaked at an orderly rushing by. "Do you know anything about these people?"

The young'un stopped and glanced at them. "Nobody looks familiar, sorry," he apologized, and rushed back to where surgery was getting underway.

Nothing. Nobody but patients. Could he save a few?

 _Without medical consent?_

Did it matter at this point?

 _To the guy with the concussion, yeah._

Despite getting that gash fixed, he wasn't waking up anytime soon.

McCoy checked the readings again. And swore. The man only had one kidney. Nobody else matched the child's. Could he get some blood? With trembling hands he hooked up the equipment.

Not nearly enough. But just some.

But blood could be replenished naturally. What about everyone else?

He wished they had Kathalan blood and organs aboard the _Enterprise_.

He wished cordrazine and other drugs could safely work on their physiology.

He wished for a lot of things, but dues ex machinas did not happen in real life.

His eyes flickered between the groups as his conscience warred.

 _How often does a chance like this happen? You can_ save _them!_

 _I can't destroy life… even if it's to save…_

 _But you have before, haven't you, now?_

Permission _is one thing, but operating without consent on someone with a non-threatening injury…_

 _They don't have a lot of time left. Better hurry up and decide._

One person.

Five people.

One dead.

Or five dead.

Action.

Negligence.

"God damn it," McCoy whispered.

And he motioned for someone to move the concussed man to the truck.

* * *

He didn't really remember the rest of the emergency after that.

He did remember as, one by one, the patients dropped off.

The heart patient was first. Too thin and too torn to be fixable, it beat courageously for a last few moments, then quit altogether. It happened so fast it still would have occurred before they could get a muscular regenerator down there.

The male with the rock in his pancreas was next. They managed to remove the rock, but the damaged organ failed faster than they could repair it.

The mother was third. They tried to save one lung, but even with support the other couldn't hold up by itself during the operation and they lost her.

After that it was battle between the man with blood loss and the child on her last kidney. McCoy looked around, even begged, for another donor but there weren't any viable matches. They found a small bag of more rare blood for him, but the toll of shock was working fast. He finally succumbed to it a few minutes before she also struggled and breathed her last.

McCoy remembered stroking her hair, and closing her eyes, and nothing after that.

* * *

"Bones…"

"Don't talk to me, Jim."

* * *

"Doctor, you have a call from-"

"This is a message from the Vulcan-"

"Dr. McCoy, please respond-"

"Bones, I don't know what happened down there but we've been redirected to Vulcan."

McCoy finally raised his head and tried to fixate on Jim. Kirk looked concerned, tracing over his bloodshot blue eyes.

"Is there a problem on Vulcan?" he asked at last. His voice was gritty.

"No." Kirk moved forward and dropped a hand on McCoy's desk. "But I keep getting court notices."

"Court… martial?"

"Just some kind of review," Kirk amended. "Before the Vulcan Medical Council of the Kathalan Branch. Haven't you read any of your messages?"

McCoy shrugged wearily at his computer. "Haven't had time."

"I've barely seen you since you returned from that planet."

"Yeah, well." McCoy stood up and shambled over to the bathroom. "They probably want me to give them some kind of report or something."

* * *

By the time they reached Vulcan he was better. Not great, but better. He knew he couldn't change the past and so he started looking forward again.

The board was reviewing key players who handled the crisis. McCoy didn't know the 'why, politics' of it, he just showed up in his dress uniform like he was supposed to and gave his report.

He was about to leave when one of the board members, Seroth, spoke.

"One last moment, Doctor McCoy."

He turned slowly.

"Although your overall command, dedication, and assistance are all to be commended, the board cannot help but note a highly questionable decision regarding medical treatment… and authority."

His stomach dropped.

It didn't matter how they knew- maybe someone saw, maybe there were cameras, maybe _he_ told somebody, he really didn't remember- they just knew.

Seroth produced a file and consulted it. "On the 5th day since you took command of the refugee surgical unit you had five critical patients brought in in dire need of transplants, correct?"

McCoy swallowed. "Yes."

"And then a sixth patient was also brought in with a mild head injury who was also a perfect donor for all of the aforementioned patients, is this also true?"

He grit his teeth. "Yes."

"Then the board questions your decision to let the five patients die-"

Kirk and Spock were up on their feet with a few other diplomatic presences as a murmur surged up through the room.

"I didn't _let_ them die!" McCoy snapped. "I did everything I could!"

"But the real problem of the transplants was not addressed, was it?" another Vulcan queried. Dr… Dr. Skann?

"I knew what the problem was, but it couldn't be fixed!"

"In fact, it could, Doctor," a serene Vulcan woman replied. "The matches for blood, pancreas, lung, kidney and heart were all at your disposal."

"No they weren't!" McCoy protested. "Somebody else was using them!"

"So you deemed it was more worthy for one to live than to save the five."

"Never!" His heart was pounding. Where was all this coming from? Why was this happening?

"You say you did everything you could, and yet you chose not to utilize the very materials that would have actually made a difference."

"Damn it, you can't just cut into somebody!" McCoy exploded. "You can't just rip his organs out of him!"

"Would it have made a difference if the donor was dead?" the woman- T'Seera, questioned.

"Well, he wasn't dead. But he would've been had I gone through with what y'all are suggesting!"

"Doctor, these are not suggestions. Five would be and are dead because you did _not_ go through with the procedure. You were sent to Kathala to help save lives, and so the most logical course of action-"

" _Logical?!"_ McCoy saw red but he also felt desperate and backed into a corner.

He didn't know when Spock appeared in front of him, between the panel, but the science officer was speaking. He dimly registered the words over his own shaking, perilous thoughts.

"If this review is to turn into a hearing on Dr. McCoy's medical decisions then he at least has the right to be represented fairly. If the board intends to follow this line of questioning, then it will recognize me as his defense." Spock stood rather boldly before them.

An old Vulcan inclined his head. "The board recognizes Spock, son of Sarek, and his position in this court."

"Spock," McCoy grabbed his sleeve. "What are you th-"

"Afterwards, Doctor."

The Vulcans had re-composed themselves. T'Seera spoke. "The fact remains, Spock, that Dr. McCoy had the ability to keep five people alive at the expense of one, and chose to let that one live at the expense of five. For a medical officer sent to aid as many people as he could during the crisis on Kathala, this is a gross act against that mandate."

"Those numbers are acknowledged," Spock conceded. "However, 'having the ability' to perform such an operation is a broad and questionable assumption. Medically speaking, yes, he possesses that capability. Psychologically, and perhaps by extent physically, he does not."

The board tittered and another murmur swept through the room. T'Seera motioned the others to be quiet and leaned forward. "Continue."

"While a doctor of McCoy's caliber is certainly able to perform those life-saving operations, the board must recognize that this incident _did not_ concern another doctor: it concerns Leonard McCoy. In all the years I have known him, I have noticed that while he does everything within his ability to _save_ a life, he cannot, by his nature, _take_ a life."

McCoy suddenly ducked his head and turned away.

"By his nature?" Seroth questioned. "If you mean to suggest because he is human then your argument is faulty: humans take lives almost as often as they give it."

"I do not suggest that his being human is the reason for his actions," Spock clarified. "It would be presumptuous to impose an entire species on one individual or the vice versa. What I mean is that Dr. McCoy is a highly empathetic individual who struggles enough with seeing others harmed- to harm one himself would go against everything he stands for, believes in, and works towards. There are documented cases where he has even refused aid to his own person if that aid was at the mortal expense of another. At this point, I would also dare to say that he is physically incapable of destroying life."

The board conferred. "You use your words oddly," Dr. Skann began. "But we acknowledge that psychological principles impact physical behavior."

Spock inclined his head.

"However," the Vulcan continued. "In either case the doctor has violated his principles. Life was destroyed. Simply because in one case it would have been active and in the other it was passive does not change that it was a deliberate decision on which path to take."

"I did not deliberately choose to let anyone die!" McCoy shouted, rushing forward. Spock blocked him sternly. "Silence."

"Medically, what were the odds that those patients would have survived without transplants?"

"Slim."

"And what were the chances of finding a donor for all them, excluding the sixth patient?"

"Practically nil."

"Then when you made the choice to not use the patient's organs, you knew with near certainty that the other five patients were condemned to die."

"I knew the chances weren't good!" McCoy spat. "It didn't mean I didn't try, though! Every one of them still went into surgery!"

"But not for the operation that would have actually worked."

" _I'm not a butcher!_ " McCoy bellowed. He didn't heed Spock's warnings. "I won't cut out a man's heart just to save another man! It's not my place to decide who lives and who dies!"

"And yet, you did just that," T'Seera pointed out. "You chose to let the one patient live and the others to suffer without the life-saving materials they needed."

" _That's not-!_ "

"Doctor, if faced with such a decision again, would you choose the same course of action?"

Seroth's question cut him deep to the core and brought McCoy up short. He couldn't imagine going through such a thing again. Once was bad enough.

"With everything objective," he said carefully. "It doesn't matter what kind of a life anybody lived… I won't cut up someone to use their body parts."

"Regardless of how many lives it may save?" the old Vulcan said bluntly.

He rubbed his face hard. "They're more than just numbers, they're more than just one versus five… it's all _life_ …"

"Your course is illogical," T'Seera stated. "It does not reflect well for a medical officer to refuse a form of treatment for his other patients."

Spock re-entered the argument. "Dr. McCoy may be illogical, but that in no way makes him incompetent," he stated firmly. "The decision to view such matters solely in terms of black and white numbers and cold facts is illogical, because it ignores other variables during the event. If McCoy was a Vulcan, he may have acted as logic dictates and transplanted the organs into the five patients. But he is not a Vulcan, and therefore his emotions, morals, and principles all factor greatly into his ultimate decision." Spock turned to him. "Am I correct that you mourn for their deaths, Doctor?"

McCoy could barely look at him. "She was only seven years old, Spock."

Spock nodded, and briefly McCoy thought he saw something akin to grief flash in the half-Vulcan's eyes. "The decision was not in any way made lightly."

"No," McCoy answered, suddenly weary. "It about killed me."

Satisfied with something, Spock readdressed the board. "Where simple logic may be the only factor in making Vulcan decisions, council, principles and intuition hold more sway in human choices. To us, saving the five patients is 'right'. To McCoy, choosing to not actively destroy even one life is 'right' by his culture and morals. This type of dilemma that we are discussing is often cause for serious philosophical debate among humans for which there is no simple answer. As such, there is no simple outcome."

The board murmured.

"Furthermore," and Spock stepped forward with conviction as his voice rose above their murmurings. "What McCoy may have been able to accomplish medically and physiologically is overridden by what he is _unable_ to accomplish emotionally and psychologically. And it is highly illogical to refute that the mind sways the body's actions."

And that cinched it. Distantly, McCoy was aware that Spock was using _his_ argument tactic: throwing the word 'logic' back in a Vulcan's face.

It still worked.

T'Seera nodded her head. "You make a valid argument, son of Sarek," she acknowledged. "We had neglected the variables of culture in this particular case. Further questions concerning the ethical decisions surrounding this incident will be dropped. You are dismissed." And just like that it was over. The board moved on. The rest of the room redirected its attention, and they were left to beam back up to the ship.

* * *

It was late evening when Spock wandered into Sickbay. A light night shift was already on duty, but nobody on it held Spock's attention. He instead made straight for Doctor McCoy's office, and carefully rang the buzzer.

After a long moment, there was a tired-sounding "come in."

Spock entered and observed the doctor not as his desk, but on the couch in the small space. He lifted his head up and blinked at Spock.

"Checking up on me?" he rasped.

"Indeed," Spock clasped his hands behind his back. "As I am given to understand it, that was a… stressful ordeal."

McCoy laughed bitterly. "There's an understatement."

Spock waited silently until McCoy spoke again. "Why did you defend me?"

"Once the board's angle of questioning became clear, a lawyer or equivalent was needed, and since I understand both Vulcan logic and am heavily acquainted with you I was the best one available to fill that void. My understanding of both sides would be able to mediate and justify a solution through common ground."

"Understanding?" McCoy looked up at him? "Your understanding of… me?"

"Indeed."

"Are you sure about that?" McCoy suddenly surged from the couch and started pacing. "Your entire argument, Spock, rested on the point that I could not willingly take a life. _Your entire point._ "

"Not 100%, but it was a great factor-"

"Exactly!" McCoy whirled an pointed a finger at him. " _Exactly_. But that can't be, Spock. It's not true. _It's not true dammit!"_

Spock was silent as he considered. "If you are counting the salt creature from M-113-"

McCoy gasped out a noise that sounded like a cross between a laugh and a sob. "And damn it, now there's _two_. I'm a scientist, same as you Spock, and I know how facts work. You made your case on the notion that I can't take a life." McCoy turned to him, and Spock was struck with the impression that his face held a million little emotions behind it.

"But I _have_. Twice! That sets precedence. That establishes capability!" McCoy was becoming inconsolable. "Damn it, Spock, _I could have saved them!_ "

Fortunately, he was a stoic Vulcan and did not reel under the force of those words. Once again, he considered his next words carefully.

"Did it save others?"

"What?" McCoy asked, barely holding on.

"The first life you took."

He looked away. "No."

Spock reconsidered. "Was it asked?"

McCoy stopped. "I don't want to talk about it."

"Doctor, this is the only question. Had the individual asked for death?"

The doctor remained still, staring directly at Spock.

"Begged."

Spock nodded serenely. "Then I would consider neither case as precedence. In one, the individual was actively harming others in the room, and would not be stopped otherwise. In the other, you compassionately responded to the patient's wants and needs. The incident on Kathala is entirely separate from both these occasions."

"Yeah, Spock," McCoy seemed to completely deflate as he felt his way back to the couch. "I get it."

"Then do not hold any of these incidents close," Spock replied. "As you would say 'what's done is done'. It is all in the past, and cannot be changed."

"I know, Spock." McCoy slowly sank his head onto his hands, but his voice remained outwardly calm. "I know."

Spock lingered by the doorway, observing the slumped shoulders. He did not know how to handle emotional wounds such as this.

Resolving that time was the best healer, he nodded "very well," at Leonard, and quietly left the doctor to his own painful comfort.

* * *

 **The Trolley Paradox: in two scenarios, a runaway trolley is barreling towards a group of people. In one, they can be saved by rerouting the trolley to a different track, where a lineman will be killed. In another, they can be saved by pushing a bystander onto the tracks and stopping the trolley that way. In the vast majority of cases, people choose the first scenario, even though it has the exact same result as the second. Someone dies either way. Kirk doesn't know about this no-win scenario.**


End file.
